EFFICIENT, EFFECTIVE AND EMPATHETIC MODEL OF CARE
Dr Enrique Steiger speaking at the PrOTeCT Stakeholder Convention in London. May 2024
“I believe the future is the collaboration of small, niche actors, who have to work together, who have to share their human resources and financial resources and to convince the large stakeholders to join so we can provide for much less money and treat many more people.”
Speaking at the PrOTeCT Stakeholder Convention 2024 in London, organized by the Global Health Institute at the American University Beirut (AUB-GHI), in collaboration with the Centre for Injury Studies at Imperial College London (CIS-ICL), Swisscross founder and Chair, Dr Enrique Steiger shared his vision of what a more efficient, effective and empathetic model of care looks like.
A veteran war surgeon, having worked in over 22 conflicts in a career spanning 30 years, Dr Steiger, was invited to speak at PrOTeCT during a session titled "Reconstructing the War-Injured Patient: Models of Care." The session focused on the experience, insights and lessons learned from tried and tested models of care for war-injured patients, focusing on reconstructive work from a clinical standpoint.
At the stakeholder convention, which brought together around 70 representatives from over 30 organizations, including researchers, medical practitioners, humanitarians, biomedical engineers, and policymakers, Dr Steiger shed light on the precarious nature of conflicts for healthcare professionals who have to be extremely adaptable to conflict-settings. He explained in conflict medicine he has had to wear “different hats” not just “as a surgeon, but as a healthcare coordinator.. and sometimes as a mechanic and radio operator.” When he began his tenure in conflict zones over 30 years ago, he worked for large humanitarian actors as a part of frontline groups working in small teams in places like Sierra Leone.
In the last five years Dr Steiger has been focused on building the Swisscross Foundation. He explained how working in a larger organization can sometimes be frustrating, so he decided to “try a different approach” with his three decades experience, focusing on reconstructive and tertiary care in conflict settings.
He explained how access to frontline conflict medicine has become more and more difficult and the lines have blurred making it hard to identify the actors. At the same time as a reconstructive surgeon, Dr Steiger maintained if fresh trauma is not taken care of “within the first 6 to 8 weeks, it automatically ends up being a reconstructive case.”
Dr Steiger, Dr Halimah ? in a Q&A session moderated by Dr Ghassan Abu Sittah
“I belong to the handful of doctors who in 1994 were involved in the Rwanda massacre. In front of my eyes I saw the same problem you are encountering today in Gaza.
I saw almost one million people get slaughtered and that traumatized me. It led to me leaving academia and I went into the private sector and built up a successful clinic in Switzerland… which allows me to spend 3 months of the year in these [conflict] zones and take care of my passion, which is humanitarian assistance.”
Swisscross was supporting the International Committee of the Red Cross (ICRCs) Trauma Centre in Tripoli, which closed down during COVID. During this time Dr Steiger was approached by an Iraqi doctor who described the need for robust health solutions for over one hundred thousand refugees in Erbil, many of whom needed reconstructive surgery, which a local overburdened health system could not provide.
Erbil became a testing ground for Dr Steiger to create a more efficient and cost-effective approach to providing reconstructive surgery. Instead of being at a level one hospital - which is on the frontline for first aid or a level two hospital, which is outside the battlefield where you will find a specialist abdominal and orthopedic surgeon, the Swisscross concept opted to work as a level 3 facility, a safe zone where patients receive specialist care across trauma fields
“Most people in war do not die directly of war injuries. They die of lack of access to medical attention or care.”
Dr Steiger described how the model Swisscross created relied on a city which had functioning hospitals, qualified and motivated healthcare workers, was safe, but still near conflict settings or had a population affected by war-injuries and neglected injuries due to conflict.
He said “We tried this in a private hospital. We didn’t go into a public hospital. What we are doing there is treating very complex cases, usually neglected because they don’t have the financial resources or they don’t have access to public health or there is missing equipment or infrastructure. We focused specifically in Iraq on IDPs and refugees. About 30% of which are located in four to five camps, but 70% - the majority - are living with family and friends.”
Dr Steiger at a patient screening during the June 2024 Humanitarian Mission at the Centre of Excellence for Complex Care, Zheen International Hospital. Erbil, Iraq.
Swisscross patient criteria include war injured populations, who have direct injuries from weapons, accidental injuries and patients with congenital differences. Patients with congenital differences are accepted by Swisscross because “these people are equally affected by war. Most people in war do not die directly of war injuries. They die of lack of access to medical attention or care.”
KURDISTAN, IRAQ
In September 2021, Swisscross opened the Centre of Excellence for Complex Care at Zheen International Hospital in Erbil, Kurdistan with the generous support of UAE AID.
Dr Steiger explained how Swisscross wanted to keep a small tight team of experts coming into the country to provide specialist care. But the country-wide screening for eligible patients is made possible through partners like the Barzani Charity Foundation, MSF in Mosul and through organizations supporting the Yezidi population. Swisscross provides the expertise and ‘super-specialists’ and equipment and instruments which are needed.
“….trainees don’t have to travel to New York, London and Paris to get the training. New York, London and Paris travel to them to give them the training.”
What sets Swisscross apart is keeping local healthcare professionals a part of the impact on patient outcomes - a mission not lost on the Kurdish Government who were “impressed” to see a focus on training and education for local healthcare providers to build up “a community of specialists of [their] own in Erbil.”
Dr Steiger explained: “We do this through Treating, Training and Mentorship. These trainees don’t have to travel to New York, London and Paris to get the training. New York, London and Paris travel to them to give them the training.” Having trained in the US, Switzerland and South America, Dr Steiger has relied on his vast network of medical experts to support the Swisscross mission.
Swisscross training has seen experts grow from three to 22 over the last three years.
“I’m really humbled by the results. We are only in the third year. But the results have been so good and the word is spreading around. The Kurdish President invited us and told us he wants us to continue the work. My hope is very soon I can hand over this project to the Government - to be funded by the government.”
Swisscross has also demonstrated to be the first in the humanitarian space to look at areas of surgeries not usually practiced in the field: “What we did is something which to my knowledge has never really been done in the humanitarian field before. I was always told you can’t do micro-surgeries. They’re very demanding, you need skills and you need equipment. We proved otherwise, it can be done [in the field]. We have excellent micro-surgeons who are doing this and training young people who are extremely eager to learn, because in much of Iraq you cannot get access to this training.”
Following the success with the first free tissue transfer or free flap surgery. Essentially the "transplantation" of healthy tissue from one site of the body to another, in order to reconstruct the existing defect, Swisscross were asked to support breast cancer treatment.
“I was told there was no breast cancer center in Iraq. So we started the first breast cancer center in Kurdistan with local and global oncologists, gynecologists and slowly the project is growing.”
AFGANISTAN
Children’s Burn Unit in Kabul, Afghanistan. March 2022
Following the continued success in Kurdistan, Dr Steiger felt that Swisscross should also look at more demanding settings, none so demanding as the fragile healthcare in Afghanistan.
“I have worked over 20 years in Afghanistan, so I said let’s go to Afghanistan. Everyone knows there was this chaotic departure of the coalition forces in 2021. But with that was also the departure of about 75% of well-trained, capable doctors in the country. They left behind a completely fractured and desolated situation of the healthcare system.”
Together with the The University Children’s Hospital in Zurich, Swisscross was already treating children in the only burns unit for children at the Indira Ghandi Hospital, Kabul.
“ What we have observed is that the space for humanitarians has gotten smaller and smaller over the last 20 years, because it's becoming more and more difficult and dangerous to work in these places.”
But with an invitation from the Taliban Government, Swisscross began a new project in Afghanistan in late 2023 focusing on maxillofacial, plastic, burn and orthopedic surgeries. Working in collaboration with EurAsian Heart Foundation, Swisscross is also supporting children’s heart surgery for congenital differences.
Dr Steiger said: “We see 30 to 40,000 children with heart defects every year. Nobody is taking care of them and families are wasting their fortunes to travel to Pakistan and India to get the surgery.”
With a precarious political landscape and growing humanitarian crisis in Afghanistan, Dr Steiger said as a neutral and independent organization, Swisscross has worked hard to build relationships in the country with the focus on treating patients at its core.
“Everything is based on trust and collaboration.”
Over time, Swiscross will also include other disciplines to support the treatment of children in Afghanistan including pediatrics and internal medicine.
Dr Steiger during a solo mission in Kabul at the Children’s Burn Unit with local surgeons at Indira Ghandi Hospital. March 2022.
THE FUTURE OF HEALTHCARE
“Our model is to keep it small. What is important is education, innovation and collaboration. We wanted to share our resources and keep our expenses low.”
Recognizing the urgent need to address trauma-related challenges, Dr Steiger shared his experience with the Stakeholder Convention, which aims to foster evidence-based interventions, improve research-to-policy translation, and enhance the understanding of trauma in contexts of conflict.
“I believe the future is the collaboration of small, niche actors, who have to work together, who have to share their human resources and financial resources and to convince the large stakeholders to join so we can provide for much less money and treat many more people.
“Our strength [at Swisscross] is that we train local people. The ownership is with local stakeholders. It is entirely based on local medical capacities and volunteers. It is a partnership model with sharing resources.”
Ultimately, Dr Steiger described a future where healthcare in Low-and-Middle-Income Countries (LMICs) reduce their dependence on foreign assistance, where local healthcare receives the training and infrastructure support to be able to manage healthcare outcomes on their own for their own citizens. A vision Swisscross is committed to.
